Transcript WCC Mandatory Training

WCC Mandatory
Training
2006
Team work
…. The whole is greater than
the sum of the parts
Team Members:
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Client
Claims Representative/Defense
Counsel
Plaintiff Attorney
Medical Case Manager
Vocational Case Manager
Vocational Evaluators
PT/OT and other Medical Providers
Cannot effect successful return to
work efficiently if
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One person working alone
Parties working at odds
Parties not working in concert
Parties not experienced
Parties without expertise in the
needed area
Rights of the Client According to
The American Nurses Association
(1988)
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A fair and comprehensive assessment
To have access to needed health and social
services
To be treated with respect and dignity
To self discrimination
To privacy and
To a grievous procedure
Confidentiality
To know the cost of services
To be notified of any changes of services
To withdraw from the case management process
Client Rights from the Maryland WCC Voc Rehab Plan
follow….
Maryland WCC Rehab Plan
Client Rights
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1. This plan is an agreement, which outlines each
party’s responsibility.
2. The Insurer will pay rehabilitation benefits.
3. The time frames agreed to by the parties can be
extended if necessary by the parties.
4. I do not have to accept any employment offered to
me unless I agree that it is suitable employment.
5. The Insurer may stop benefit payments if the
Insurer determines that rehabilitation services are no
longer necessary.
6. If my benefit payments are stopped for any reason
with which I do not agree, I have the right to request
a hearing.
7. I have a right to be an active participant in my
rehabilitation.
8. I have a right to confer with an attorney regarding
the terms of the rehabilitation plan.
Claims Representative/Defense
Counsel
The role of claim adjusters and defense
attorneys in the rehabilitation process is to
know and understand the parameters of
the law and to ensure its accurate
application.
Maryland law requires employers/ insurers to
provide rehabilitation services under
specific guidelines.
Under these guidelines, claim adjusters must
procure professional rehabilitation services
which are reasonably necessary to secure
suitable gainful employment. Good Practice Manual
Claims Representative Cont.
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The role of the adjuster is to investigate
whether or not an injury is compensable.
To qualify for compensation of an
occupational injury or disease –
The employee must have an accident that
causes an injury during the course of
employment.
The injury must have occurred in the
course of employment.
The employee must be exposed to the
disease during the course of employment.
The injury must be unexpected and usually
traceable to a definite time, place, and
cause. Excerpted from an article in the Nursing Spectrum
Insurance Company Cont.
Claim adjusters and defense attorneys
actions are guided by statutory
requirements as well as the
contractual obligations set forth in
the insurance policy.
To the extent that these statutory
requirements and contractual
obligations are met, claim adjusters
and defense attorneys have acted
ethically. Good Practice Manual
Plaintiff Attorney
The claimant's attorney has a critical role in
the vocational rehabilitation process.
The claimant's attorney functions as both a
champion of rights of the client and
counselor to the informational and
emotional needs of the claimant.
He or she can help to shape the process into
the best possible chance for claimant's
return to suitable gainful employment.
The plaintiff attorney can set the tone for how
claimant works with other team members.
It is important to enlist his or her help with
any problems. Good Practice Manual
Medical Case Manager
“The Commission's regulations
state that these case
management services include
but are not limited to
interviewing the worker for the
purposes of implementing and
coordinating services with the
injured worker and the health
care providers.” Good Practice Manual
The Maryland Board of Nursing Regulations
Governing Worker Compensation Medical Case
Managers state that medical case management
for the injured worker includes but is not limited
to:
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Case Assessment
Implementation And Coordination Of
Services With The Injured Worker's
Family
Health Care Provider
Evaluation Of Treatment Results
Coordinating Community Reentry
Return To Work With The Employer
Of Injury
Recommendations For Further
Vocational Rehabilitation Services
The major functions which the
RN-WCCM performs include:
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Case Management
Task Assignment
Life Care Planning
Advocacy
Cost Containment
Ethical Decision Making
Vocational Counselors
Rehabilitation Counselors are committed to
facilitating personal, social, and economic
independence of individuals.
Work with people, programs, institutions, and
service delivery systems.
Rehabilitation counselors recognize that both
action and inaction can be facilitating or
debilitating.
May provide counseling, vocational exploration
and vocational assessment; evaluation of
social, medical, vocational, and psychiatric
information, job placement and job
development services, and other
rehabilitation services.
Must demonstrate adherence to ethical
standards and must ensure that the
standards are enforced vigorously.
CRCC
Vocational Evaluators
Vocational Evaluation is a specialty profession within Rehabilitation. The focus
is on identifying appropriate employment outcomes for individuals with
disabilities utilizing a holistic approach.
In contrast to the brief assessment typically completed by Vocational
Counselors, a vocational evaluation (career assessment) is more
comprehensive and includes assessment of interests, temperaments,
career awareness, transferable skills, work skills through real or simulated
work, work behaviors, job seeking and keeping skills, achievement,
aptitude, dexterity, learning style, accommodations and supports.
Vocational evaluators must adhere to ethical standards of practice for the
profession in accordance with:
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International Professional Association – Vocational Evaluation & Career
Assessment Professionals (VECAP)
National Certifying Body - The Commission on Certification of Work Adjustment &
Vocational Evaluation Specialists (CCWAVES)
State Standards – Division of Vocational Rehabilitation Services Career
Assessment Services System (CAS)
Vocational evaluators are certified through CCWAVES. The Certified
Vocational Evaluator (CVE) designation assures that minimum
competencies are achieved.
Milestones
Although Each Member Plays a
different role and may have a
different emphasis – in general,
the following apply:
 Assessment
 Plan
 Evaluation/Re-evaluate
 Resolution
Assessment
An assessment is the process of collecting
and analyzing all the medical, educational,
vocational, social, legal, and economic
information of an injured employee,
including the injured employee's present
physical and mental ability to participate in
rehabilitation services and determining the
appropriate rehabilitation services
reasonably necessary to return the injured
employee to suitable gainful employment.
Good Practice Manual
When is Vocational Evaluation
(Career Assessment) Appropriate
for an Injured Worker?
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If a clear vocational goal cannot be
identified using less intensive
assessment means
If there are numerous complicating
factors affecting the individual’s
ability to return to work
If a second opinion is needed in
highly contested cases
As each individual is unique, the assessment
process will vary depending upon his/her
particular circumstances. The following
hierarchy outlines the various levels of
assessment:
 Referral Confirmation
 File Review
 Initial Interview
Areas covered during the initial interview include:
a. Medical Information
b. Educational Background
c. Vocational History
d. Social –
e. Legal Information
f. Economic Circumstances
 Job Analysis
 Assessment of Functional Capacity (PT/OT)
 Transferable Work Skills Analysis (vocational case
managers)
 Vocational Assessment or Evaluation (vocational case
managers, vocational evaluators)
Suitable Gainful Employment
Workers’ Compensation Law
LE 9-670(c) defines “suitable gainful
employment” as employment,
including self-employment, that
restores the disable covered
employee, to the extent as possible,
to the level of support of the time of:
 If an accidental personal injury, the
accidental personal injury; or
 If an occupational disease,
disablement form occupational
disease.
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Return to work hierarchy
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Same employer, same job
Same employer, different job
Different employer, same job
Different employer, different job
On the job training
Retraining for new career
Self employment
Independent living
RTW Same Employer/Job
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Can the client return to preinjury level of function?
Can the client return to work in
an alternate capacity?
Will some combination be
feasible?
Light Duty
 Modified Duty
 Transitional Return to Work
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RTW New Employer/Job
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It is essential that the initial career goal
selected by the injured worker be
researched in the local market to determine
its feasibility.
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Is the job available?
Would the injured worker be physically and
mentally capable of performing the demands of
the job as defined by employers?
Would the injured worker need further
qualifications (such as formal training to obtain
entry into the chosen occupation?
Is it possible to obtain on-the-job training in this
occupation?
Would a combination of formal training and job
placement be more effective?
Resolution
Once the injured worker is returned to
function/work, the rehabilitation
professional must follow-up to make
sure that no problems, such as:
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changes in the job duties or work
environment
non-cooperation of the employee, his
co-workers, or the supervisor
The rehabilitation professional should
also verify that the new employee's
performance is acceptable to the
supervisor/employer.
PT/OT Case Management
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Licensed health care
professional
Registered with the
Workers’ Compensation
Commission
PT/OT Activities
Contraindications for participating in
Industrial Rehabilitation
• The client is not medically stable
• The client has other medical problems that would
adversely be affected by the testing, such as
cardiac difficulties
Guidelines for the paperwork
• Physician’s order not required
• Informed consent to evaluate and/or to treat
• Medical Release of Records
• Medical Records
• Job Description
• Functional Job Description
• Information for PT/OT primarily from Julie Howar’s
Maryland Workers’ Compensation Training for
Physical and Occupational Therapists 2005
What are the basic services?
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Functional Capacity Evaluation
Work Hardening Program
Work Conditioning Program
Job Analysis
Functional Capacity
Evaluation
An objective determination of the level of
function.
Components could include:
Medical History
Musculoskeletal Assessment including
range of motion, strength
neurological functioning
Worker Behaviors
Functional Abilities including present physical
demand level
Ability to perform essential functions
Impressions and Recommendations
Definition of Work Hardening
“A highly structured, goal oriented,
individualized treatment program
designed to return the person to work.”
Work hardening programs use real or
simulated work activities designed to
restore physical, behavioral, and
vocational function.
CARF
Definition of Work Conditioning
“a work related, intensive, and goal-
oriented treatment program specifically
designed to restore an individual’s
systemic, neuro-muscular (strength,
endurance, flexibility, etc.) and
cardiopulmonary function.” The objective
of the work conditioning program is to
restore the client’s physical capacity and
function so the client can “return to
work”.
APTA
Medical Case Management
Today, case management strategies
have been embraced in a managed
care environment within the workers’
compensation marketplace. the
nurse case manager role will
continue to expand. Essential skills
include expert clinical abilities, highlevel communication techniques, and
knowledge of planning and work
reentry and reintegration for
maximum effectiveness. Excerpt from an
article in the Nursing Spectrum
Medical Case Manager
Activities
Data collection and assessment: The First Report of Injury is
frequently the first factual account of the accident that telephonic
case managers receive.
The case manager needs to obtain, review, and analyze all pertinent
medical information, including medical history, current status,
diagnosis, prognosis, and current treatment plan.
Data analysis, diagnosis, and establishment of goals: After the acute
phase of the injury, the case manager will assess the patient’s
temporary or permanent alterations in function resulting from the
injury.
Community and Work Reintegration: The final phase of the case
management process is facilitating the Return to Work or
permanent modified alternative duty.
In collaboration with the medical provider, the insured worker
reaches medical stability and maximum improvement, and all
treatment ceases.
If competitive employment is not an option for the client, the case
manager helps identify community resources and/or vocational
rehabilitation counseling.
Excerpt from an article in the Nursing Spectrum
Vocational Case Management
Assess the progress being made in reaching the
vocational goal.
Meetings determined on a case by case basis.
Responsibilities for communicating the results of these
meetings and any necessary plan revisions should
have been identified in the rehabilitation plan
All parties who agreed to the components of the
rehabilitation plan must be kept apprised of its
progress.
As return to work is the ultimate goal of the rehabilitation
plan, the provision of job placement services is critical
to the process.
Before an injured worker is actually placed in a job, the
rehabilitation professional must make sure that both the
employer and the injured worker understand the
conditions of employment,
It is advisable that the position being offered is discussed
with the treating physician, possibly utilizing a job
analysis.
Vocational Case Management
Activities
If in job development, you should
strive to provide 10 – 15 job
leads per week, obtain the same
amount from the injured worker,
schedule at least one interview
per week, and attend one or two
if feasible. Appropriate leads
beyond those listed on the
rehabilitation plan may also be
pursued
ADI = After Date of
Injury
NLT= No Longer
Than
NTE = Not To
Exceed
PT/OT Time Based Injury Treatment Algorithm
Insurance Company / Case Manager Communication System
4-12 Weeks
1-3 Weeks
Injury
Medical
Exam
& Treatment
NLT-2 Days
Acute PT
NTE - 6 Weeks
Medical Re-Evaluation
NLT - 21 Days
3 Months and over
Active PT
NTE - 6 Weeks
Vocational
Consultant
(Job Placement)
Functional
Capacity
Evaluation
3 Months ADI
Medical ReEvaluation
NLT - 12 Weeks
Job Task
Analysis
Return To Work
Medical Re-Evaluation
NLT - 24 Weeks
Work Hardening
NTE - 6 Weeks
Release To Work
Full Duty
Release To Work
Modified Duty
Settlement
and / or
Case Closure
Acute Injury Phase 1-3 weeks
Sub-Acute Injury Phase 4-12 weeks
Chronic Injury Phase 3 months & over
75% of People Return To Work
80% of People Have Returned To Work
90% of People Have Returned To Work
Within 24 Hours
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Open File/Obtain records
Contact all parties (plaintiff
attorney permission required for
client)
Acknowledgement Letters
State Forms – R33 and VR-7?
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PT/OT –VR7 referral form.
General Time Frames
for Case Management
Follow
Within two weeks if possible:
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Send letter confirming date and
location of initial interview
Meet with client
Confirm all demographic/contact
information
Relate hierarchy and role
Obtain signed release
Prior to Initial Report
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Obtain any additional necessary
information, for example:
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Medicals
Job Description
Transferable Skills Analysis*/Testing
Employer contact re: employment status
Report recommendations to all
parties
Immediately
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Update claims representative
and injured worker’s attorney:
Return to work (include details)
 No show/no call
 Non-attendance of interview
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Return calls from either claims
representative or injured
worker’s attorney.
Begin case management, following your
own recommendations and revise as
necessary.
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For Vocational Staff: You must complete
a Maryland WCC Rehabilitation Plan that
will be signed by all parties. You may use
simultaneous faxes to distribute, attach
individual signatures to the body of the plan
and file with the WCC for stipulation.
Attached to the plan should be the initial
report, Functional capacities
documentation, and labor market
documentation. Suitable gainful
employment definitions are a factor in
deciding which job targets to include.
Complete WCC-R33 every 90 days, if
assigned.
Initial Report
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Demographic Information
Medical, vocational and educational history
Psycho-social and financial information that
is pertinent
Current functioning level
Client interests/goals
Recommendations with time frames
Complete WCC-R33 if assigned and VR7
referral form
Begin case management, following
your own recommendations and revise
as necessary Cont.
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For Medical Staff: If an injured worker is
unable to return to work in his previous
occupation, you may feel that training
concurrent with medical case management
(for example, GED) would be beneficial. If
this is the case, a vocational counselor will
need to complete a rehabilitation plan,
submit it to all parties for their signature,
and file it with the WCC for stipulation.
Complete WCC-R33 every 90 days
Documentation
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Document your activities in your case
notes.
Include pertinent details without being
unnecessarily wordy.
ALWAYS INCLUDE insurance company file
number in message or email.
State your name (spell it if it is unusual and
the claims representative is not familiar
with you).
Provide contact numbers where you can be
easily reached.
Copy all correspondence to the WCC and
claims representative and/or attorney
(depending to whom you are writing).
Monthly Reporting
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Report at least monthly.
Some insurance companies have guidelines in
terms of report formats/time frames and billing
codes.
Be mindful of your language. Always include an
overall summary.
Always include recommendations with timeframes.
Your report should not come as a surprise to any
party as you are maintaining constant verbal
communication throughout the life of the case.
Reports are primarily reviewed by the Commission
at the time of a hearing, so they should be objective.
Closure
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For Medical Staff: This is normally done when an
injured worker reaches MMI, returns to work, or
case management can no longer have a benefit to
the injured worker.
For Vocational Staff: This is normally done when
an injured worker returns to work, settles his case,
states he is not interested in vocational services and
his attorney concurs, or proves non-cooperative.
For PT/OT: This is normally done when the injured
worker has reached a plateau, functionally and will
not benefit from further service.
Closure reports should summarize your work on the
entire file.
Complete WCC-R33 if assigned &/or VR2 closure
form
Task Assignments
Expectations on how you will handle task assignments
often vary between insurance companies and, even,
claims representatives. Here a few tips to ensure
your task assignment goes smoothly:
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Clarify the scope of the current assignment
Update the referral source within 24 hours of
completion (same day if possible)
Notify the referral source of any additional needs
you identify
If asked to close the file ask if the referral source
would like you to call them at a future date to
determine if additional services are needed
Rehab Plans
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Research your plan – the new WCC
guidelines require objective support for your
goals in working with injured workers.
ACINET.ORG is a great site for obtaining
general labor market information.
Write your plan. It should be completed
immediately following initial assessment after
verbally receiving authorization of your
recommendations.
Forward the plan via fax or email to the
claims representative.
Forward the claims representative-signed
plan to the injured worker’s attorney and the
injured worker Review the plan with the
injured worker at the earliest possible time
and attempt to get signature, don’t forget to
have the injured worker sign the rights and
responsibilities statement.
Rehab Plans Cont.
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Once all signatures are obtained, forward
to the WCC with the stipulation as soon as
possible for a stipulation order. Stipulation
makes this agreement a legal, binding
document. Until the rehab plan is
stipulated it is an informal contract.
When you receive the notice of stipulation
copy all parties.
If you receive approval to extend a plan
from an claims representative complete
page one of the plan indicating an
extension and send to the WCC. Copy all
parties.
All OJT, Training, and Self-employment
plans must also include labor market
surveys.